Fatigue and Anaesthetists 2013

Transcription

1 Fatigue and Anaesthetists 2013 Published by The Association of Anaesthetists of Great Britain & Ireland 21 Portland Place, London, W1B 1PY Telephone Fax

2 Membership of the working party (details correct at the start of the working party process) Dr Kathleen Ferguson Dr Felicity Howard Dr Chris Idzikowski Dr Barry Nicholls Dr Mike Peters Dr Felicity Plaat AAGBI, Chair of working party GAT Edinburgh University Sleep Centre AAGBI BMA AAGBI The Association of Anaesthetists of Great Britain & Ireland 2013.

3 Contents 1. Preface 2 2. Recommendations 3 3. Introduction 4 4. Why are anaesthetists at risk of fatigue? 6 5. What are the risks? 7 6. How can fatigue be avoided, modified, or managed? 8 7. References Appendices This is a consensus document produced by expert members of a Working Party established by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It updates and replaces previous guidance published in July What other guideline statements are available on this topic? There are several guideline statements published by other healthcare professional groups within the UK and overseas. Some high fidelity industries provide evidence based guidance on fatigue management to their employees. Why was this guideline developed? The original guideline (2004) was developed as a reference document for individuals and departments when considering the effects of hours of work and type of work undertaken in anaesthesia on clinician's performance and well being. The primary goal was to improve patient safety. How and why does this statement differ from existing guidelines? This new guidance is an update on the previous document. Additional research on the impact of the European working time directive on clinician performance and fatigue provides new evidence to support the recommendations. Date of review:

4 1. Preface The first edition of the Fatigue and Anaesthetists guideline was published in 2004 in paper and extended web versions. The document provided recommendations on how to anticipate and mitigate the effects of fatigue for anaesthetists in the work place. A major driver in producing the document was to reduce risk to patients by considering the impact of fatigue on anaesthetist s performance and wellbeing and thus in turn on the incidence of critical incidents in practice. Since 2004, the effects of the New Deal agreement for junior doctors working hours and the enforcement of the European Working Time Directive (EWTD) have taxed departments in their ability to deliver service and training. Hours of work were cut drastically; previously rotas often covered over 80 hours per week. Acute care specialities have been adversely affected and anaesthesia in particular due to the intensity of out-of-hours work and the number of rotas to be covered by single departments. Nine years on, 48 hours are the suggested contractual maximum for job plans. Out-of-hours rotas have survived the move by variable means: introduction of hybrid rotas, complex on-call arrangements and full and partial shift patterns. The resulting squeeze on training time has produced a knock-on effect on consultant working patterns: many departments have consultants either first or second on-call out of hours in theatre, labour ward and intensive care medicine. Evidence is growing of new working patterns, shift types and their effects in the health care setting. There is also increasing evidence of the detrimental effects on extended working hours and shift patterns on individual wellbeing [1,2]. The Fatigue and Anaesthetists publication is being refreshed adding current evidence to support the recommendations. Changing service and training demands plus increased requirement for professional accountability all add to the pressure of a high-intensity time pressured job. This AAGBI resource hopes to serve as an aid in managing fatigue in departments and individuals. 2

5 2. Recommendations In keeping with the GMC guidance in Good Medical Practice [3], every doctor is required to provide safe and effective care and therefore should be aware of the issues of fatigue. (2004) Departments must have a plan to manage staff at all grades who have undertaken an onerous duty period and consider themselves unfit to continue work. (2004) Job plans should be constructed such that they are not likely to lead to predictable fatigue. (2004) Routine rest breaks should be implemented. (2004) Handover protocols should be used before and after every rest break. (2004) Rest facilities and on-call rooms should be available for staff to nap during shifts or sleep post call. (Updated 2013) Resident on call staff should have suitable accommodation. (2004) Refreshments should be available at all times. (2004) On-call responsibilities should be reviewed regularly and in particular in the older anaesthetist, taking into consideration subjective assessment of fatigue (consider seeking advice from an accredited specialist in occupational medicine). (Updated 2013) Education on fatigue, its causes, mitigating factors, and its impact in healthcare should be a priority for departments of anaesthesia. (New 2013) 3

6 3. Introduction What is fatigue? Fatigue is a subjective feeling of the need to sleep, an increased physiological drive to fall asleep and a state of decreased alertness [4]. Its consequences include a decreased capacity to perform mental or physical tasks and are manifest in reduced physiological performance and cognitive impairment [5]. Inadequate sleep is the most important single factor impacting on fatigue. Common scenarios leading to sleep-related fatigue include insufficient sleep, prolonged wakefulness and being awake when normally one would be asleep [6]. Fatigue may manifest itself in characteristic behaviour patterns which vary between individuals: yawning and difficulty staying awake, poor concentration and co-ordination, head drooping, eye rubbing or heavy eye lids, general feelings of lethargy, lacking motivation, error events and lapses in attention [5]. As an alternative to self or colleague-assessment of observed behaviours, the risk of fatigue may be quantified subjectively using tools such as the Samm Perelli checklist [7]. Objective assessment is out of the individual s capability but subjective assessment along with a sleep diary and good sleep hygiene techniques can be used to demonstrate appropriate rest during and between periods of work. What is sleep and how much of it is optimum? Sleep is a complex physiological process where the brain remains active but is less responsive to external stimuli whilst undertaking tissue healing and repair and consolidation of learning and memory. Normal sleep consists of several phases and is associated with specific EEG patterns and physiological changes. Sleep follows a diurnal rhythm sleep-wake cycle and is controlled by a circadian pacemaker in the suprachiasmatic nucleus in hypothalamus. Research has demonstrated that the circadian pacemaker would naturally function within a 25 hour cycle. Light input via the retina and other external stimuli called zeitgebers act to maintain the sleep-wake cycle within the 24 hour day night cycle [8,9]. Sleepiness peaks twice in any 24 hour period: hrs and hrs. The circadian rhythm ensures that the best sleep is achieved when going to bed between and 02.00hrs and that there is difficulty in sleeping between 08.00hrs and 12.00hrs and 17.00hrs and 21.00hrs. The potential adverse impact upon shift workers is obvious. Most adults require eight hours of restorative sleep each night. This varies between individuals. Restorative sleep may be inadequate due to reduced quality (awakenings during sleep periods) or insufficient time afforded to sleep. When sleep is restricted for two or more consecutive nights, a sleep debt accumulates. Two consecutive nights of restorative sleep is required to recover from significant sleep loss [10]. Evidence shows that moderate sleep restriction to six hours per night for two weeks leads to performance reduction equivalent to one night with total sleep deprivation [11]. 4

7 When wakefulness is extended beyond what is normal (16-18 hours) cognitive function is impaired. This may manifest as slow response time, increase in attention lapse frequency, impaired memory functions, addition and subtraction ability and decision making. Periods of extended wakefulness may be quantified in terms of the effects of an equivalent blood alcohol level [12]: after 20 hours of wakefulness (coincident with a circadian low point) performance is impaired equivalent to that with a blood alcohol of 0.1% (100mg/100ml of blood). The legal limit for driving in the UK is 80mg/100ml of blood. Sleep patterns change with age. The requirement for eight hours sleep remains but the periods of REM sleep are reduced leading to sleep fragmentation [13]. There is a reduction in the depth and consolidation of sleep. Older people suffer from frequent and early awakenings with an exaggerated dip in arousal mid afternoon. The ability to recover from a sleep debt is decreased and so the older anaesthetist may be less able to cope with night shift work [14,15]. Fatigued individuals may suffer from sleep lapses or microsleeps where they remain unresponsive to external stimuli for very short periods of time (seconds to minutes). These episodes of sleep are spontaneous, brief and uncontrolled [16]. Sleep inertia is characterised by a temporary disturbance in performance on awakening. Its duration depends on the depth of sleep at the time of wakening and sleep deprivation enhances its appearance [17]. 5

8 4. Why are anaesthetists at risk of fatigue? Intensity and type of working Fatigue is a function of time on task; the longer the hours of working the greater risk of fatigue developing [18]. It is also important to recognise that time spent awake may be substantial given the other demands when balancing daily living and working. This may be particularly relevant to staff with young families and those with other responsibilities. There is a near exponential rise in errors associated with increased time on task. Long shifts (12 hours) lead to a doubling of risk as compared to an eight hour shift [19]. This must be taken into consideration when planning for long surgeries. The previous working party concluded that a 12 hour working day is not acceptable working practice for an individual anaesthetist of any grade. Current evidence would agree with this statement. The complexity of tasks affects the state of fatigue. Regular activity serves to reduce fatigue whilst mundane and lengthy tasks increase the likelihood of fatigue developing [20]. Sleep disturbance on-call On call patterns of work predispose to poor quality sleep for several possible reasons: unplanned interruptions move sleep opportunities out of sync with circadian rhythm and poor timing of zeitgeber stimuli adversely affect the circadian sleep/wake cycle. In a recent online survey of AAGBI members (Appendix 1) > 60% of respondents reported working out of hours as an on call pattern. This activity was associated with post-call tiredness and sleep debt. Sleep deprivation shift patterns Individuals who work shift patterns are at risk of developing poor sleep hygiene due to circadian rhythm disruption. The relative risk of adverse incident occurrence increases as shifts move from morning to afternoon to night. Risk is greatest at the beginning of a night shift. Risk increase over successive night shifts from 17% on the first night compared to 36% on the fourth [19]. 6

9 5. What are the risks? Performance and Safety With adverse effects of fatigue on performance and safety accepted, work should be organised to take place in daytime hours making use of increased alertness and peak performance [21, 22]. Regular breaks should be incorporated into the working day [23] with comprehensive handover protocols used in support [24]. Wellbeing Evidence is accruing to support claims of an association between impaired health and sleep disturbance and sleep deprivation. Shift workers may experience: poor dietary habits, peptic ulceration, increased prevalence of obesity and the development of the diabetic state. There is some suggestion of an increased risk of developing hypertension, transient ischaemic attacks and cerebro-vascular accidents. It has been suggested that there is an increased risk of breast cancer in Scandinavian nurses working night shifts but a causal association has not been confirmed [25]. Disturbed circadian homeostasis is implicated in the pathophysiology of these conditions [26]. Individuals should be encouraged to follow good sleep hygiene practices and to prepare for periods of duty by ensuring adequate restorative sleep before and after rostered duties. Service provision Restricted hours of work in conjunction with reducing trainee numbers and central control of career grade expansion creates a staffing void for service delivery. Career grade staff cannot fill this gap without appropriate consideration of the consultant and staff and associate specialist doctor role in job planning and the effects of fatigue [27]. All grades of anaesthetist perform out of hours work either in an on-call capacity or in shift patterns. The provision of rest breaks within and at the end of periods of work must be catered for with-in department rostering. Planning of shifts must take into account lengths of shift, numbers of nights worked consecutively, and periods of rest before return to work. Rotas should not consist of more than four nights in a row. Rotas of nine hours provide the minimum effect on cognitive function but are difficult and costly (staffing) to organise. Rotas in a forward rolling pattern (day-evening-night) provide the least adverse effects on sleep patterns [28]. The effects of ageing on sleep and fatigue mean that specific consideration must be made when allocating of out-of-hours duties to the older anaesthetist. 7

10 6. How can fatigue be avoided, modified, or managed? Strategies to reduce and mitigate the effects of fatigue include: good sleep hygiene, techniques to minimise sleep disturbance (Appendix 2), napping, caffeine ingestion, bright light exposure, regular rest breaks and exercise, avoiding hunger and dehydration, maintaining alertness and avoiding alcohol ingestion prior to a period of duty [ 21,29]. Several industries and organisations such as aviation, transport services, the oil industry and Queensland Government health department [5] have introduced fatigue management systems into their practices. This proactive approach to managing fatigue in the workplace is based on education for all levels of the team. Diary evidence of sleep patterns and hours of work are kept and assessed to determine the risk to the individual and the service caused by fatigue. The initiative in Queensland Health is supported by government legislation [30] and departments are required to have contingency plans to support staff when fatigue raises the risk level unacceptably high. Monitoring is a routine. Electronic devices and Apps are available both to facilitate maintaining a diary of activity and sleep and also for self assessment of mental performance. Less is known of the effects that non-technical skill development in individuals and teams may have on the monitoring, reporting and management of fatigue in medical practice. The recent GMC review of the effects of the EWTD alludes to this point and highlights this as an area for future research [1,2]. 8

11 7. References 1. Durham University. The Impact of the Working Time Regulations on Medical Education and Training: Literature Review ning Literature_Review.pdf_ pdf (accessed 04/06/2013). 2. Durham University. The Impact of the Working Time Regulations on Medical Education and Training: Final Report on Primary Research. ning Final_Report_on_Primary_Research.pdf_ pdf (accessed 04/06/2013). 3. General Medical Council. Duties of a doctor. (accessed 04/06/2013). 4. Murray D, Dodds C. The effect of sleep disruption on performance of anaesthetists a pilot study. Anaesthesia 2003; 58: Queensland Government. Fatigue risk management system resource pack. (accessed 04/06/2013). 6. International Association of Oil and Gas Producers. Managing fatigue in the workplace. (accessed 04/06/2013). 7. Defense Technical Information Center Online. Estimating aircrew fatigue: a technique with implications to airlift operations. (accessed 04/06/2013). 8. National Institute of Neurological Disorders and Stroke. Brain basics: understanding sleep. (accessed 04/06/2013). 9. Toh KL. Basic science review of circadian rhythm biology and circadian sleep disorders. Annals of the Academy of Medicine, Singapore 2008; 37: Bonnet MH. Sleep Deprivation. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine 3rd edn. Philadelphia: Saunders, 2000: Von Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose response effects on neurobehavioural functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003; 26: Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388: Redline S, Kirchner HL, Quan SF, Gottlieb DJ, Kapur V, Newman A. The effects of age, sex, ethnicity, and sleep-disordered breathing on sleep architecture. Archives of Internal Medicine 2004; 164: Katz JD. Issues of concern for the aging anesthesiologist. Anesthesia & Analgesia 2001; 92: Folkard S. Shift work, safety, and aging. Chronobiology International 2008; 25: Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in Anesthesia: implications and strategies for patient and provider safety. Anesthesiology 2002; 97:

12 17. Knauth P. Extended Work Periods. Industrial Health 2007; 45: Tassi P, Muzet A. Sleep Inertia. Sleep Medicine Reviews 2000; 4: Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology 1990; 73: Folkard S, Lombardi DA, Tucker PT. Shiftwork: safety, sleepiness and sleep. Industrial Health 2005; 43: Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on Quality and Patient Safety 2007; 33: Tucker P, Folkard S, Macdonald I. Rest breaks and accident risk. Lancet 2003; 361: British Medical Association. Safe handover: safe patients guidance on clinical handover for clinicians and managers. /media/files/pdfs/practical%20advice%20at%20work/contracts/safe%20handover%20s afe%20patients.pdf (accessed 04/06/2013). 25. Kolstad HA. Nightshift work and risk of breast cancer and other cancers a critical review of the epidemiologic evidence. Scandinavian Journal of Work, Environment and Health 2008; 34: British Medical Association. Health effects of working unsocial hours and shift work. A briefing paper from the BMA Board of Science Q1LVMF7XR5FUI6MQNG287F.pdf (accessed 04/01/2013). [BMA members only] 27. Association of Anaesthetists of Great Britain and Ireland. Working Arrangements for Consultant Anaesthetists in the United Kingdom. London: AAGBI, Horrocks N, Pounder R. Working the night shift: preparation, survival and recovery a guide for junior doctors. Clinical Medicine 2006; 6: Garbariono S, Mascialino B, Penco MA, et al. Professional shift-work drivers who adopt prophylactic naps can reduce the risk of car accidents during night work. Sleep 2004; 27: Australian Government. Work-related fatigue. Summary of recent regulatory developments elated_fatigue_summay_recent_regulatory_development.pdf (accessed 04/06/2013). Link to sleep diary information: pdf?view=Standard 10

13 8. Appendix 1 Membership Questionnaire A Have you ever napped / fallen asleep / microslept whilst undertaking anaesthesia? Total number responding 178 Yes No Do you have knowledge of a colleague who has napped /fallen asleep/ microslept whilst undertaking anaesthesia? How old are you in years? Which grade do you work in? Training 45 SAS 11 Consultant 121 Which pattern of work do you undertake to provide out-of-hours service? Shift 46 Rostered extended hours 7 On-call 109 Other 13 Have you made mistakes in your work which you relate to tiredness? Have you experienced tiredness at your work which you relate to your work pattern? Has fatigue affected you personal life outside the work place? How do you counteract fatigue related to your work? % (n) Always Usually Sometimes Never Rating average Napping 2.9 (5) 15.6 (27) 59.0 (102) 22.5 (39) 3.01 Caffeine 31.3 (55) 30.1 (53) 28.4 (50) 10.2 (18) 2.18 Leave 5.3 (9) 9.9 (17) 41.6 (71) 43.3 (71) 3.23 Post-call sleep 15.8 (27) 36.3 (62) 32.7 (56) 16.2 (26) 2.47 Sleep debt 12.3 ( (55) 44.2 (72) 9.8 (16) 2.52 Early to bed 9.6 (17) 36.7 (65) 50.8 (90) 2.8 (5) 2.47 activity level 0.6 (1) 19.0 (33) 50.6 (88) 29.9 (52) 3.10 Frequent 1.2 (2) 17.3 (30) 52.6 (91) 28.9 (50) 3.09 breaks Ask for help 0.6 (1) 4.6 (8) 51.4 (90) 43.4 (76)

14 Membership Questionnaire B Have you ever napped / fallen asleep / microslept whilst undertaking anaesthesia? Total number responding 187 Yes No Do you have knowledge of a colleague who has napped /fallen asleep/ microslept whilst undertaking anaesthesia? Yes 125 No 63 How old are you in years? Which grade do you work in? Training 48 SAS 11 Consultant 127 Which pattern of work do you undertake to provide out-of-hours service? Shift 48 Rostered extended hours 8 On call 113 Other 15 How many hours of sleep do you consider you need each night before work the following day? >11 0 How many hours on average do you actually get on nights before clinical work? >11 2 Do you think you get sufficient sleep to meet the demands of your job? Yes No Do you regularly have to catch up on sleep following routine clinical duties? Yes No Do you regularly have to catch up on sleep following out-of-hours clinical duties? Yes No

15 Appendix 2 Minimise sleep disturbance: Maintain a sleep diary alongside an hours-of-work record Regular bedtime and wake-up time Sustained adequate sleep Two nights of good sleep before work period Bedroom quiet, dark and cool Avoid heavy eating and drinking before bedtime No alcohol, caffeine, nicotine close to bedtime No exercise <3 hours before bedtime 13

16 Appendix 3 Sample Sleep Diary Date and Name Mon Tues Wed Thurs Frid Sat Sun Time to bed Time to wake Hours of sleep No of wakenings Total time awake How long to fall asleep How awake did I feel when I got up 1 = wide awake 2 = awake but a little tired 3 = sleepy Caffeinated drinks and times Alcoholic drinks and times Exercise and times How sleepy did I feel l during the day 1 = so sleepy I struggled to stay awake 2 = somewhat tired 3 = fairly alert 4 = wide awake 14

17 Appendix 4 Subjective assessment of fatigue Samn Perelli checklist (Accessed by 1. Fully alert, wide awake 2. Very lively, responsive, but not at peak 3. Ok, somewhat fresh 4. A little tired, less than fresh 5. Moderately tired, let down 6. Extremely tired, very difficult to concentrate 7. Completely exhausted, unable to function effectively 15